As payers continue to move from the fee-for-service (FFS) model that ties payments to the number and type of services performed and to value-based care (VBC) arrangements that connect payment amounts to the results of patient services, providers must leverage solutions that better enable them to keep patients healthy and lower the cost required to do so.
Enter remote patient monitoring (RPM) and chronic care management (CCM).
RPM and CCM are two services rapidly growing in popularity among providers, patients, and payers. The increased adoption of RPM and CCM programs can be attributable, in part, to their inherent ability to help achieve the worthwhile, patient-centered goals of value-based care — regardless of whether they are being used by providers participating in VBC arrangements.
While remote patient monitoring and chronic care management are distinct services, they both enable organizations in VBC arrangements to provide more proactive and ongoing patient management outside of traditional care settings. The use of RPM and CCM technologies help strengthen patient engagement, reduce healthcare costs, improve quality of care, and drive better patient outcomes.
Providers in value-based care arrangements can get the best of RPM and CCM by pairing them together under a comprehensive care management framework, leading to a more holistic approach to managing chronic diseases, preventing acute exacerbations, and supporting patients with their ongoing healthcare needs.
Let's look more closely at why adding RPM and CCM programs should be viewed as an imperative by value-based care organizations, and then further discuss the value of pursuing a comprehensive care management program.
Remote Patient Monitoring for Value-Based Care
Remote patient monitoring involves the use of technology to enable providers to, as the name suggests, remotely monitor patients' vitals and continuously collect, analyze, and act upon real-time data concerning a patient's condition. Patients can use a variety of remote patient monitoring devices (e.g., blood pressure monitor, weight monitor, blood glucose monitor, pulse oximeter) to deliver their health data to providers. This virtual interaction between patients and providers empowers care teams to achieve earlier detection of potential health issues and deliver high-quality care. It also empowers patients to take a more active role in checking and managing their health, fostering greater patient engagement and treatment plan adherence. 
Alignment With the Value-Based Care Model
It's easy to see how remote patient monitoring aligns with the goals of a value-based care model. RPM directly contributes to improved outcomes, especially for patients with chronic conditions like diabetes, hypertension, and heart disease as well as maternal health conditions like gestational hypertension and gestational diabetes. RPM facilitates the continuous monitoring of these conditions while reducing the number of in-person visits by patients to their care providers. In-person visits can be costly and difficult for patients, particularly those with challenging health-related social needs. By providing care teams with continuous patient health data, RPM allows for timely clinical interventions that reduce the likelihood of hospital admissions and readmissions (which have an average cost exceeding $14,000) and emergency room visits. For example, using RPM for heart failure patients has been shown to reduce hospital admissions by detecting early signs of deterioration, enabling cardiologists and other healthcare providers to quickly adjust treatment plans and prevent a worsening condition that necessitates a hospital visit.
Improvements in Care Quality
In addition to reducing healthcare costs, remote monitoring drives improvements in quality of care by facilitating a more personalized approach to patient care. Through an RPM program, providers can better tailor treatment plans through their access to real-time patient data. This helps ensure every patient receives care appropriate to their current and unique health status. One could argue that personalized care takes on even greater importance in a value-based care environment, where VBC success is measured not only by patient outcomes but by the efficiency and effectiveness of care to patients rendered.
Strengthened Patient Engagement
Remote patient monitoring also fosters improved communication between patients and their care teams. Since patients know their health is being monitored, and they are engaging with their care teams whenever vitals are transmitted via their RPM device, patients are more likely to adhere to treatment protocols. Providers can engage with patients more frequently and easily through virtual visits and check-ins. This enhanced level of communication should contribute to improvements in patient involvement and patient satisfaction while promoting early and timely interventions when data indicates these are necessary, thus decreasing the risk of complications and improving outcomes.
Chronic Care Management for Value-Based Care
Chronic care management focuses on providing continuous care and ongoing support for those patients with multiple chronic conditions. A CCM program involves a combination of regular check-ins with patients, care coordination, medication management and reconciliation, education, and other services — defined in a comprehensive care plan — aimed at giving patients the knowledge, tools, and support to better manage their conditions and disease progression
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Challenge of Chronic Diseases
Chronic diseases are the leading drivers of healthcare costs in the United States and account for the most illness, disability, and death in the country. Research shows that a growing proportion of people in America are dealing with multiple chronic conditions. More than 40% have 2 or more chronic conditions, and 12% have at least five chronic conditions.
Tangible Value-Based Care Benefits
Chronic care management helps healthcare organizations in value-based care arrangements directly address the needs of these high-risk, high-cost individuals. Improvements in care and disease management for those with multiple chronic conditions translates to reduced costs and improved outcomes. Like remote patient monitoring, CCM is intended to help prevent the exacerbation of health conditions, which can lead to costly interventions, like hospital admissions and emergency room visits.
Ongoing Communication to Support Proactive Care
Through a chronic care management program, providers leverage continuous monitoring of patient health, regular follow-up appointments, and the personalized, comprehensive care plan to improve patient adherence to treatment plans and identify timely, worthwhile changes to these plans and patient lifestyles. Thanks to consistent communication with patients and increased patient engagement with their care team and health, CCM helps detect potential health problems before they become acute, supporting a proactive approach to care. With this information, patients can receive earlier interventions that can prevent hospitalizations and ultimately improve quality and longevity of life.
Enhanced Care Coordination
Chronic care management is proven to improve care coordination, which is essential for managing those patients with chronic conditions which require input from multiple healthcare providers. Patients with multiple chronic conditions typically see multiple specialists. Poor care coordination can lead to care gaps and increase the likelihood of fragmented care. Fragmented care for chronic illnesses has been defined as "noncontinuous, low‐quality, duplicated, or omitted pivotal care coordination from multiple healthcare providers or multiple healthcare settings." These have been shown to contribute to worsening chronic illnesses, preventable hospital readmissions, and increased healthcare costs. CCM serves as the focal point of coordination for all aspects of a patient's care, helping ensure all providers involved in the patient's chronic disease management are current on the overall treatment plan and that the patient receives the consistent, comprehensive care that avoids the problems associated with fragmented care.
Reaping the Benefits of Preventive Care
CCM also supports value-based healthcare organizations by further emphasizing and supporting preventive care and patient education. By helping patients better understand their chronic conditions and the steps to take to better manage and control them, CCM empowers patients to become more active participants in their healthcare, which helps raise patient satisfaction. Studies have shown that patients who are engaged and "activated" (i.e., possess the skills, ability, and willingness to manage their own health and care) experience improved health outcomes at lower costs compared to less activated patients.
Comprehensive Care Management for Value-Based Care
While remote patient monitoring and chronic care management bring tremendous value to healthcare organizations in VBC arrangements on their own, their true potential is realized when they are integrated into a comprehensive care management strategy. Comprehensive care management involves pairing RPM, CCM, and other preventive services to create a continuous and more streamlined care experience for patients with chronic conditions.
In a comprehensive care management program, RPM provides healthcare teams with real-time data on patient health and the effects of chronic diseases. This data is then used to further shape the care plans developed through CCM, allowing for timelier adjustments to treatment and better ensuring patients receive the most appropriate care based on their current health and vitals. Integration of RPM and CCM into a comprehensive care management program enables healthcare providers to better detect early warning signs of health declines and intervene before the condition worsens and necessitates a bigger and more expensive intervention (e.g., hospitalization).
Combining RPM and CCM also enhances care coordination and efficiency in the delivery of care. For example, consider a patient using an RPM blood pressure monitor who experiences an unexpected increase in their blood pressure. A designated care coordinator who sees this data can relay the information to the patient's primary care physician. The primary care provider can then engage with the patient and take an action, like adjusting a medication, to help prevent a potential health crisis.
RPM and CCM: A Win-Win for Organizations in Value-Based Care Arrangements
It's clear that value-based care is steadily transforming the healthcare industry, shifting some of the focus from volume of care for patients to the value of care and placing a priority on patient outcomes and cost-efficiency rather than quantity of services. During an interview with the American Medical Association (AMA) earlier this year, Narayana Murali, MD, chief medical officer of medicine services at Geisinger Health shared some eye-opening figures concerning the transition to value-based reimbursement models. Statistics he cited include the following:
- Nearly 94 million Americans are in an accountable care organization arrangement.
- Nearly three in four payers believe that alternative payment models will rise and are moving towards value-based care.
- Medicare Advantage value-based care plans have doubled compared to 2018.
- The number of commercial value-based care plans have also significantly increased.
Dr. Murali told AMA, "We are transitioning from a traditional fee-for-service model to better outcomes, quality, as well as better patient experience at a lower total cost of care — value-based care, the holy grail for over two decades."
The Value-Based Care Rewards of RPM and CCM
For healthcare organizations in value-based care arrangements, adding RPM and CCM can enable greater clinical and financial success while strengthening appeal to patients, payers, and physicians. The good news for value-based care organizations is that the work required to set up, launch, and grow RPM, CCM, or comprehensive care management programs has been greatly simplified. This is attributable to the emergence of software and services companies, like Prevounce, that specialize in helping organizations in VBC arrangements and FFS providers in the provision of high-quality, low-cost preventive medical services, chronic care management and remote patient management.
To learn how Prevounce can help your value-based care organization maximize the benefits of RPM and CCM, book a consultation today.